Hypothesising an alternative: Applying the scientific process to drug policy

June 29, 2012

As you may know, earlier this month I gave evidence to the Home Affairs Select Committee’s (HASC) current inquiry into drugs. We had a wide-ranging discussion across many aspects of alcohol and drug harms particularly in relation to the value of drug law reform and decriminalisation. (You can watch the session, including the interesting evidence of the subsequent witnesses online). I strongly believe that we should focus on public health approaches to the drug problem, and decriminalise the possession of drugs for personal use, for the following simple reason;- If users are addicted then they are ill, and criminal sanctions are an inappropriate way to deal with an illness. If they are not addicted then criminalisation will almost always lead to greater harms to the user than the effects of the drug. For example, it can severely limit career options in public service and prevent travel to some countries particularly the USA.

However, it was clear from questions from several of the HASC committee that they are very frightened that reducing or removing the criminal penalties for drug possession will lead to greater use – and then greater harms overall. This is a reasonable hypothesis. Forming hypotheses represents the first step in thinking scientifically. Next, we should test the hypothesis against the available evidence. I think that the following evidence allows us to reject this hypothesis.

1. There is good evidence that decriminalisation does not radically increase drug use and can reduce some measures of harm, as shown by a balanced review of the first ten years of the Portugal experience of decriminalisation. The collapse of society predicted by some did not occur; they had slight increases in drug use followed by slighter falls, which compares favourably with the trends in the neighbouring countries and the rest of the EU over the same period. More importantly, young people growing up under this system used fewer drugs, and harms and deaths from heroin went down as a result of a treatment-centred attitude replacing a punishment-centred approach. Remarkably, young people who have grown up in the Netherlands, where cannabis use is decriminalised, are less likely to be users of the drug than young people in Britain, the US and many other countries which criminalise young users. Perhaps the cachet of illegality here promotes some use.

2. An increase in the availability of some drugs may actually lead to a reduction in the use of other more harmful drugs, so reducing net harms to society. We saw a noteworthy example of this in the past few years with the advent of the stimulant mephedrone. As this became popular, cocaine users seem to have switched to mephedrone and cocaine deaths fell by almost a quarter. Mephedrone gives a strong high and has potential to harm and kill, but seems much less likely to kill than cocaine. By switching, cocaine users reduced their risk of dying. It appears that the mephedrone phase caused the first significant impact on the steady rise of cocaine deaths we had seen in 20 years. It seems to have been a major – if unplanned and temporary – public health success. Relatively fewer young people progress to problematic drug use in the Netherlands than in most comparable Western countries. There is evidence that the legalization of medical cannabis in some states of the USA has been associated with a considerable reduction in fatal road traffic accidents, comparable with the benefits of laws requiring seatbelts. This, the authors of the study show, is mostly due to the large drop in the number of fatal crashes involving alcohol as people appear to substitute cannabis for drinking.

3. Regulating access to drugs such as cannabis as in the Dutch model reduces the need for users to go to dealers. So it minimises their exposure to people whose main goal is to get their clients onto the most addictive substances such as heroin and crack. Indeed this was the main reason why the Dutch initiated the coffee shop model in the first place and it has been successful; by separating the markets of cannabis and heroin they have among the lowest rates of heroin use in young people in Europe. The Netherlands is now in the process of restricting tourists’ access, on a city by city basis, to coffeeshops, making them primarily for Dutch residents. As drug tourism was never the aim of the coffeeshop policy, this change is not without logic, however, given that there is already a mature market for cannabis that may now be pushed into the illicit market with a correlating effect on street disorder and crime, as has already been seen in Maastricht.

4. Approaches to dealing with addicted users which swap punishment for healthcare have been successful. In 1994, despite strong resistance from the UN, Switzerland began a program which allowed long-term treatment-resistant addicts to take clean pharmaceutical heroin under medical supervision. This has been criticized for maintaining rather than ending addictions, but it has stabilised chaotic lives, allowing users to be socially reintegrated, getting homes and sometimes jobs, and as well as removing the health harms associated with polluted, inconsistent street drugs. Addicts in this treatment get fitter, they virtually never overdose, and very few die. Unlike those in other regimes, most stay in treatment, allowing some to progress later to abstinence. It isn’t just the addicts who benefit; crime fell enormously once users could access heroin from the State rather than profiteering dealers. The State, and taxpayers don’t lose out in this arrangement, the expensive program more than pays for itself in healthcare and law enforcement savings.

5. Approaches which explicitly reject an evidence-based public health approach, but instead focus on incarceration and criminalisation of addicts, continue to utterly fail, at enormous financial and human cost. The Global Commission on Drugs Policy have just published a new evidence-rich report, well worth reading, which focuses on the effect of different approaches to drug users on the HIV/AIDS pandemic. The spread of disease cannot be considered a wholly natural, biological phenomenon, it is also social, economic and very political. Political choices determine whether a huge majority or a small minority of new HIV infections are caused by injecting drug use. In Russia, where organisations trying to help heroin addicts look after their health have been persecuted, a million people are HIV positive, over 80% of them through their drug habit. In comparison, here in the UK, Margaret Thatcher, the only PM we’ve had with a science degree, heeded her scientific advisors, brushed off moralising critics, and instituted a needle-exchange programme. Since then, UK policy has at least accepted the need for harm-reduction alongside punishment, and less than 2% of new HIV infections in 2010 were caused by injecting drugs. In the US, where incarceration rates are high, but harm-reduction measures (like distributing clean hypodermics) is politically taboo, unfunded or even illegal, HIV spreads in prisons where syringes carrying heroin and HIV are passed around. Whilst use of prescription heroin in a clean needle rarely harms anyone besides the user, these preventable HIV infections across the world in injecting drug users cause infections in their sexual partners and continually infuse HIV into wider society.

6. Treating addicts with more humanity doesn’t make drug use look more appealing. The idea that less punitive approaches would encourage drug use is again a reasonable hypothesis, but science demands that hypotheses are tested against the evidence. The Swiss evidence shows that rather than making heroin more popular, numbers of people becoming addicts have steadily fallen. It has been suggested that whilst heroin use can appear rebellious where the focus is on punishment (think of Pete Doherty photographed with an entourage of police, or sashaying in and out of court), in Switzerland, young people think of addicts as simply ill, which deters use. It is no surprise that Switzerland’s policy has won broad democratic support and has inspired similarly successful projects in other European countries, including small trials here in the UK. It’s also no surprise that much of the world remains strongly opposed to this approach despite such strong evidence that it works.

Moreover criminalisation produces many perverse consequences that actually increase the harms of drugs and costs to society. Criminal networks coalesce around drug supply; America in the era of alcohol prohibition was the heyday of organised crime. The lack of quality control in illegal drug markets leads to wholly unnecessary harms like deadly outbreaks of anthrax in heroin injectors. Dealers with concerns only for their profits adulterate and mis-describe drugs, for example selling the much more potent and riskier drug PMMA as the less risky ecstasy. Badly enacted prohibition also severely limits research so denies the possible therapeutic benefits of drugs such as MDMA for treating PTSD and psilocybin for treating depression and the anxiety of cancer.

It is now time to begin to introduce a more rational evidence-based approach to drug policy to minimise harms. We must consider all drugs, including alcohol, as part of the problem to be tackled. I hope that the Select Committee will recommend a more progressive approach than the current one of interdiction and punishment which has, and will continue to fail.

Incredibly wise words, one can only hope that the HASC Inquiry will listen to reason and at least decriminalise drug use in a similar way as to Portugal. They will also hopefully relax the laws further regarding cannabis.

It’s frustrating listening to some of the MPs in the inquiry who seem to refuse to listen to scientific evidence and instead cling to the misconception that continuing with prohibition, which is incredibly counter-productive. They use the term ‘controlled substances’ when they are anything but!

It is good to see you including alcohol and tobacco in the list of harms too, which is something a lot of people don’t think about… when in fact they cause more problems than all the other drugs combined!

Under a legalised, controlled and regulated framework we can all benefit – recreational users can use their drug of choice in relative safety, addicts can get the treatment they need and everyone else will benefit from the law enforcement savings, tax income and safer streets (amongst many other benefits!).

i wish more people would listen to you Dave! If only politicians wernt ruled by fear and votes and maybe this country would be in a lot better place. You are a good role model for todays future leaders and scientists, i hope you get more and more coverage!

I hope and pray that the HASC drugs inquiry will conclude that the common sense, evidence-based approach you set out above is the only rational and responsible way forward.

However, my worry is that prohibition is sustained by vested interests which seek to subvert the inquiry and use it as a sop to public opinion. A sprinkling of celebrities has given the inquiry sufficient public visibility that the government can claim it has given proper consideration to the issues whatever the inquiry recommends.

The selection of witnesses so far has been extraordinary. The most extreme prohibitionist views have been given a platform and you were treated as if your evidence was a counterbalance to Brett, Gyngell and Hitchens, yet you should have been regarded as neutral, providing independent scientific evidence.

I have expressed this and other concerns to the inquiry and as a result CLEAR was invited to submit a supplementary witness statement which has now been published on the HASC website.

The reasons that cannabis remains prohibited in Britain and which need to be overturned before we can progress to a rational policy are:

1. The power of the alcohol lobby
2. The power of the US prohibition industry
3. The Daily Mail campaign of lies, distortion and forged scientific evidence
4. Corrupt and cowardly politicans
5. The unlawful monopoly of medicinal cannabis granted to GW Pharmaceuticals.

i honestly think the monopoly that GWP have will be the worst barricade for us to overcome.
As you said before Peter, they pumped alot of money into the goverment to get it granted to them, so they will most likely fight it all the way so they dont lose there ace in the hole

meanwhile…. back on the “shop floor” the Recovery Community is suffering due to lack of funding for actually getting people well. The NHS is still putting lives at risk by continuing to employ people in charge who do not understand the nature of addiction and who would rather spend the money on brief interventions and traditional “treatment” options. There is no accountability for Drug or Alcohol commissioning locally – The government is doubly wasting tax payers money and messing with peoples lives!.

Our data provide circumstantial evidence of drug-seeking behaviour before death, including increasing use of multiple doctors and disproportionate increases in prescriptions for drugs prone to misuse. The extent to which this behaviour predicts heroin-related death (rather than merely being a feature of ongoing heroin use itself) requires further investigation. Lifestyle characteristics typical of many young heroin users (such as homelessness, itinerancy, poverty and poor diet) may increase both the use of different doctors and the rate at which doctors are seen, 15 as well as vulnerability to fatal overdose. 16 The association between heroin addiction and psychopathology 17 may also create a legitimate need for medical services. The relationship between declining physical or mental health before death and increasing medical visitation rates is well documented in chronically ill 18 and suicidal 19 , 20 patients, and both factors might contribute to the doctor-shopping behaviour exhibited by the patients in this study.

According to BMA “Alcohol misuse: tackling the UK epidemic February 2008″ 1.1 million people are pyshically dependent on alcohol in this country. That is a frightening statistic when you look at how damaging alcohol is at this level.
Peter Reynols you publish a couple af articles and thats it, no action no changes. Its almost like your actually working for the five things you listed.

Cannabis is not prohibited it’s possession is, the major and only reason that cannabis possession is prohibited is the UN single convention on narcotics, not the conspiraloon theories about alcohol lobbies or monopolies, any country seeking to change drug law immediately gets threatened and pressured by the US
government as recently seen in the Northern Mariana Islands, the UK government simply and understandably does not wish to anger or antagonise the US government so legalisation will never happen in the UK, all countries with a sensible and realistic approach have decriminalised, that option is less troublesome for all concerned as it needs no law change merely an order to ignore and not apply current law, complete decriminalisation is the only route and anything else is a waste of time.

Hi Prof
I always find it strange the idea that if you decriminalize a substance that it would encourage drug use. As a person who does use (currently illicit) drugs but does not drink alcohol. People will always use whatever is their drug of choice regardless of legality and will not become heroin addicts overnight. In saying that it is probably less harmful than being an alcoholic. ;-) Thanks

The link in the second point “cocaine deaths fell by almost a quarter.” doesn’t link to an article saying cocaine deaths fell by a quarter. It links to a 2010 article saying that the mephedrone epidemic started around 2008 and they don’t have figures for 2008 and 2009 yet…

[…] As you may know, earlier this month I gave evidence to the Home Affairs Select Committee’s (HASC) current inquiry into drugs. We had a wide-ranging discussion across many aspects of alcohol and d… […]

Dear Prof Nutt, surely the scientific process is being held hostage by corporate greed and gov collusion. I believe they’re running scared of the truth coming out. This is just like when President GHW Bush cancelled the us federal cannabis program in the 1980’s stating that “people might get the wrong idea that cannabis is actually medicinally beneficial” The truth is in 1977 George Herbert Walker Bush left his position as director of the CIA and was appointed as director of Eli Lilly Pharmaceuticals by Dan Qualye’s father & family who along with Bush are major shareholders in Lilly. Then in 1982 Omni Magazine & other sources report that Eli Lilly, Abbot Labs, Pfizer, Smith, Kline & French and other drug companies would lose HUNDREDS OF MILLIONS TO BILLIONS OF DOLLARS annually if cannabis were legal in the US alone. Now, do you really think that the “powers that be” want us to cure ourselves free of charge??????

It’s time to wake up and start questioning instead of merely accepting…

After listening to your highly interesting feature on the Guardians Science Weekly podcast and hearing about the issues about finding funding for research about illegal drugs I had an idea.

I don’t know if you’re aware, but recently there have been quite some media attention on social media fuelled crowd fundraising for non-profit causes. One of the go to sites for this is indiegogo.com (I am in no way affiliated). For example this (admittedly quite silly but none the less very successful) campaign to raise money to the National Wildlife Federation and the American Cancer Society raised over $220,024 in just a few weeks. Check it out here: http://www.indiegogo.com/bearlovegood

I am sure there would be a possibility to repeat this to fund one of your projects if we would use social media sites such as Reddit.com. Reddit.com has an history of being open to research like yours and it has a strong track record of big fund raisers. Feel free to read more about their previous fundraisors here: http://en.wikipedia.org/wiki/Reddit (under the topic “Community and culture”).

Feel free to contact me via email if you would like any help or guidance to setting up one of these fundraisors or how to use the potential of for example Reddit.com.

I am hereby contacting you, following a visit of your blog, which I find very appropriate for a publication.

I am an employee of Bloggingbooks publishing house, which is the new publishing brand of the well-established scientific publishing house, known as SVH Verlag. We are currently actively looking for new authors.

Bloggingbooks would like to broaden its publication’s portfolio and in this respect, comes my question: would you have any interest in publishing your blog posts into book format?

You will find information about bloggingbooks on our homepage (bloggingbooks.net). The best way to get in touch with me will be per e-mail.

I realise I’m a month behind the last comment, but I have a question and I wonder whether someone can point me in the right direction:

How many drugs are made illegal by the laws pertaining to structurally similar molecules i.e. by Shulgin-like modifications of tryptamine and phenethylamine? Is it in the millions, billions, trillions, or more?

I guess we can’t even hint at what proportion of those many drugs are pharmacologically active.

I am so glad for someone with some sense and reason such as yourself. I myself am a recovering heroin addict (on subutex, never used needles). I stopped using on top about a year ago because frankly I got bored with it in the end (I think most people retire from addiction rather than give up with will power).
I am one of many ‘functioning addicts’. Even at my worst I still worked, contributed to society, cared about other people. I never made anyone else suffer if for any reason I couldn’t get my script or use. As far as I’m concerned, it is my own problem and something I have I do solve myself.

Too often in rehab, you feel like someone else’s good deed or mascot. The acheivement and responsibility is taken away from you as is the recognition that you are an adult, who made this choice (same as with smoking).

Sadly, people are frightened of the truth about drugs and addicts. Any mention of antiprohibition and they imagine a drug free-for-all. In fact it would mean more rules and legislation. I would certainly rather be in the hands of a doctor than a dealer. I grew to hate those people but I also understand the economics that has driven them to it (they’re often illegal immigrants or with no real prospects in life. I felt most sorry for the Jamaican women that did it (and their kids).

I feel that the War on drugs has truly failed. It is a war on apathy and despair and ignorance we should be fighting. Heroin is just a bit of powder to me, once I realised that, it made things easier, regardless of its effects (this was my reaction to my drug worker telling me heroin was a powerful drug – actually, humans are much more powerful and the ones making the choices.

Anyway, I have a lot to say on the subject but I’d better go now.
All the beast
Kelly

ps. and no I did not become an addict overnight (as is portrayed by most anti-drug warnings). It took a lot of determination on my part (2 weeks daily use) and I was aware what the outcome would be but I was a long time self-harmer and heroin offered a nicer alternative to cut marks on my arm. A lot of users have said heroin saved their life. I don’t find that odd because I was suicidal and took it with that aim but then found it made life much more bearable and I could meet everyones demands and be perfect for them. (I’ve read that the ancient Greeks used opium as an anti-depressant)
Surely a non-addict can imagine or relate to that. It’s a very human failing and condition I’m afraid.

I also feel that heroin (at least in my case) was not the problem but the symptom of a problem. Hence the war is on hope not drugs.

While supporting your work and the breath of fresh air you have brought to this acrimonious debate, I take issue with the following point made in your statement above: ‘…minimises their exposure to people whose main goal is to get their clients onto the most addictive substances such as heroin and crack’.This is shear tabloid rubbish worthy of the Mail and indicates your lack of knowledge of cannabis use and cannabis culture, and the unfortunate playing into the hands of the rabid anti-cannabis lobby. Of course there are multi-drug dealers who don’t care what they sell, but the majority of cannabis suppliers are cannabis users mostly supplying friends, are not smack users or delaers, and have no interest at all in getting their customers onto ‘the most addictive substances’. This old slur against dealers really should be put to rest, they are for the most part honourable, decent people who provide a service at great personal risk that should be performed by legitimate companies in the marketplace. When the law is changed, many of them become precisely that, given the opportunity to be legit. They are not archetypal evil pushers taking advantage of poor addicts, and never were, it’s just tabloid hyperbole.

From admin;- Fair point. There are plenty of cannabis deals, trades and gifts between friends and people who are not archetypes of evil! I don’t think that is David’s considered view either. Even so, is it possible that people who are part of what you call ‘the cannabis culture’ are not really representative of the majority of cannabis use? I think some people buy cannabis from dealers interested in profit maximisation without being part of any community of users that might have a collective will to reduce harm.

Well said! I suspect however, that government policy is a product of pressure from the USA whose agenda is to promote worldwide adoption of its “war on drugs” policy. They would no doubt cite the zero tolerance policy for example in Singapore as a success. Whilst the Murdoch press and media, close allies of the USA right remain such a large influence on opinion in both UK and USA it will be difficult to get a rational approach to the subject. One wonders what motivates those who lobby for criminalisation at the highest levels, a moral stance or something much more sinister!

According to your argument, would you argue that legalising the future use of MDMA to treat post traumatic stress disorder would not encourage use of the drug to others? Do you think the comedown effects of the drug would negatively effect users, encouraging them to continually use the drug or can it be used safely for treatment?

From admin;- Good point. ‘Abuse liability’ has to be properly evaluated before licencing any drug for medical treatment. It is unlikely though that this will be a major obstacle to medical use for MDMA. Medical use of morphine or diamorphine (heroin) as a painkiller after surgery or accidents doesn’t seem to cause people to seek it out for non-medical use afterwards. MDMA will be even safer, as the treatment is a one-off MDMA-assisted therapy session, not a long-term prescription that would be likely to risk psychological dependency. Context is crucial, in trials of MDMA assisted therapy the patient is likely to see the drug as a facilitator to useful therapy, not a cure in itself, so they might not see teh drug itself as tempting on its own. Trials of the method, and other scientific experiments using MDMA in a one-off manner have not found the comedown to be a noticable problem. It may be that the comedown after clubbing on ecstasy is the result of a combination on MDMA with exertion, and messing up the body-clock by dancing all night!

Does your site have a contact page? I’m having a tough time locating it but, I’d
like to shoot you an email. I’ve got some creative ideas for your blog you might be interested in hearing. Either way, great blog and I look forward to seeing it grow over time.

[…] The greatest problem, as Nutt sees it, with drug reclassification or legalisation, is the dangers of purely hedonistic use and all of the associated problems of reduced productivity (Soma, anyone?), thinking in general, and burden on the health services through rising addiction: I realise that I prematurely postulate these dangers in the absence of proper epidemiological study, but in the UK, the health service deals with a significant number of alcohol-related problems. Would the legalisation of some drugs (cannabis, for example) lead to an overall increase in the health burden, or simply a reorganisation of it? Overuse of any drugs, be it alcohol, caffeine, tobacco, can lead to different serious health problems, and moderation is not possible for some addiction-prone individuals. Actually, Nutt gives a very good summary of the effects of drug law reforms that have taken place in other countries. […]

Professor Nutt, great respect to the work you are doing.
As usual, a text full of good rational reasoning.

On your unique mission, it seems very important to me that all information is correct and the common myths and misconceptions are avoided. And so, I have to voice one little objection, about point 3:

You mention dealers who sell marihuana and also sell hard drugs and are supposedly interested to make their clients addicted to them.

Do such people exist? Or are such demonic dealers of everything another myth?
Maybe they exist in the UK.

But from my own personal experience, 15 years of using all kinds of substances recreationally, I have a hard time believing that this is common.

In my experience, people who sell soft drugs usually want nothing to do with hard drugs, it’s a different world. They would not touch them themselves and absolutely not sell them. And they certainly don’t want to make anybody addicted to anything. There is no reason to, people are hungry enough for psychoactives, they do not need to be manipulated into using them.

I did my share of experimenting with hard drugs too, many years ago, and even in that world, I never encountered individuals who would seem to be trying to “make” somebody addicted. I encountered the exact opposite: people who worried about me being a beginner, hurting myself or becoming addicted. I had people refuse to sell to me, when they thought I was irresponsible, or not experienced enough.

Of course, I can imagine there are evil individuals like you described. But I never met any, and I met lots of people who did not fit that description at all, so I am inclined to believe that it is not a typical situation, that a pot dealer would want you hooked on crack or heroin, more it sounds completely absurd.

Correct me please, if it indeed IS typical in the UK, I am from Eastern Europe and never visited UK, in that case I apologize, and I am really grateful for the way our drug scene is.

From Admin, not David;-
Thanks Iliana, I think you’re right, the text appears to make an unfair generalisation, I don’t expect that was David’s intention. I recall (but can’t find) an interesting ethnographic article about cannabis dealers, which distinguished between two types. The first was as you describe, had a relationship with a group of regular and faithful clients, often didn’t make too much profit as they’d be generous or smoke with clients, was sometimes female, and dealt cannabis (and nothing else) from their home. The second type deals on the street, virtually always male, is often in a vulnerable economic situation (perhaps feeding an addiction, perhaps being controlled by figures further up the crime ladder) and doesn’t have a fixed group of clients. They’re more likely to offer different types of drugs, and their first priority may be to sell the greatest value of drugs in each transaction, as they may never see the client again. In the latter case there is the risk that someone looking to buy cannabis gets offered other stuff. Unfortunately, naive teenagers looking to score some cannabis won’t have the contacts to access the first type and may find it easier to encounter the second type of dealer. In both cases, I think demonising the dealers isn’t helpful.